Which Breast Cancer Surgery is Right For You?

By Catherine GuthrieFriday, Oct. 05, 2007

Lester Lefkowitz / The Image Bank / Getty

Breast cancer can be a devastating diagnosis. Add an unwanted surgery to the mix, and women may find themselves filled with regret. But that's what's happening to thousands of newly diagnosed breast cancer patients who feel compelled to make rapid-fire treatment decisions, say experts in the field.

"Ten years ago, women were pressured into mastectomy, and now it's just the opposite," says Dr. Dale Collins, a plastic surgeon who specializes in breast reconstruction and is director of the comprehensive breast oncology program at Dartmouth Medical School. "Some women are being strong-armed into lumpectomy."

In a generation, breast cancer treatment did an about-face. Up until the 1970s, breast cancer meant mastectomy. Period. Then, along came a less invasive option  lumpectomy with radiation (also known as breast-conserving surgery or BCS). By the early 1980s, studies deemed lumpectomy with radiation tantamount to mastectomy in that both offered similar rates of recurrence and survival. But, to the consternation of women's health advocates, mastectomy remained the status quo.

Eventually, two big yanks on the wheel led to a course correction. For starters, in the 1980s, 20 states passed legislation requiring surgeons to inform women of both treatment options. Secondly, in 1990, the National Cancer Institute officially declared lumpectomy with radiation "preferable" to mastectomy for women with early-stage breast cancer.

As a result, rates of mastectomy toppled from virtually 100% in the 1980s to an estimated 30% today. Some experts say mission accomplished. But others wonder if there's been an overcorrection. Says Collins, "The pendulum has swung away from mastectomies to almost forcing women toward lumpectomy and radiation."

Many physicians assume that given the choice between mastectomy and lumpectomy with radiation, women with early-stage breast cancer will choose the less-invasive option, says Dr. Steven Katz, a breast cancer researcher and professor in the departments of medicine and health management and policy at the University of Michigan. Yet his research shows just the opposite  the more involved a woman is in the decision-making process, the more apt she is to choose a mastectomy.

Yet only one-third of women with early-stage breast cancer settle on mastectomy, so where do things become unglued? Probably at the time of diagnosis. The average woman with early-stage breast cancer goes from diagnosis to operating room in two weeks. Katz suspects women are pressured into making a lightening-fast decisions. As a result, they are more likely to sign-on to a surgeon's preferred treatment plan rather than carefully explore the pros and cons of each option and intuit their own preference.

Research supports his hunch. In studies of early-stage breast cancer patients, 20% reported being dissatisfied with their decision for surgery and 50% said they didn't fully participate in the treatment decision to the extent they desired. So who's influencing the decision? More often than not it's the physicians. "The unfortunate reality is that doctors have a bias and they will pull patients in that direction every time," says Collins.

Even the most well-meaning physicians can unintentionally weight their words. Consider the subtleties of gender bias. Male surgeons may be more likely to push for lumpectomy over mastectomy because men perceive the loss of a breast differently than women, says Katz. "From a man's perspective, disfiguring a woman is a very high price to pay; from a woman's perspective, the loss of a breast may be a way of zeroing out the problem. Men see disfigurement where women see survival."

The bottom line is that either treatment option  mastectomy or lumpectomy with radiation  is reasonable for most women with early-stage breast cancer as long as the decision is well informed, says Collins. To help women weigh their options, the Center for Shared Decision Making at Dartmouth-Hitchcock Medical Center developed a video that fully presents the treatment options in unbiased language. For more information or to order a copy of the video, visit the Center for Shared Decision Making website.

In the meantime, here are four things to consider if you find yourself on the receiving end of a breast cancer diagnosis:

Take your time. "One of the biggest problems is that a diagnosis of breast cancer is perceived to be a medical emergency when it's not," says Katz. His advice? Try to avoid making any definitive treatment decisions, such as what kind of surgery, during you first doctor's visit.

Get a second opinion. Consult another physician, especially if you aren't happy with how your doctor is presenting your options or if the advice feels one-sided. Taking the time to find a physician you feel comfortable with pays off. Studies show women who take an active role in choosing their surgeon (as opposed to automatically accepting a referral from a doctor or insurance company) receive higher-quality care and are happier with the end result.

Find an experienced doctor. Studies show the more experienced the surgeon, the more satisfied women are with their breast cancer surgeries. Find a surgeon who is either a breast cancer specialist or performs a minimum of 50 breast cancer operations a year, says Katz.

Educate yourself. Ask your doctor if he or she has discussed ALL the treatment options with you. For a detailed description of your treatment options contact the American Cancer Society by calling 800.ACS.2345 or visiting www.cancer.org. Expert-approved treatment guidelines are also available from the National Comprehensive Cancer Network.